5/12/2017 1 Phani K. Dantuluri, MD Division of Shoulder and Elbow & Upper Extremity Surgery Resurgens Orthopaedics Emory University Midtown Hospital Emory St.Joseph’s Hospital Postoperative Management of Elbow Surgery
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Phani K. Dantuluri, MDDivision of Shoulder and Elbow & Upper Extremity Surgery
Resurgens OrthopaedicsEmory University Midtown Hospital
Emory St.Joseph’s Hospital
Postoperative Management of Elbow Surgery
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6 weeks Postoperative follow-up
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Orthogonal Plating
Orthogonal Plating
Orthogonal Plating
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Orthogonal Plating
Orthogonal Plating
Orthogonal Plating
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Orthogonal Plating
Orthogonal Plating
Orthogonal Plating
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Parallel Plating
Posterior Exposure
Paralell Plating
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Case
78 y.o. male
Independent
Active
CT Scan
CT Scan
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CT Scan
CT Scan
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Postop Xrays
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Follow up Xrays
Bone QualityQuality of Fracture FixationFracture ComplexityPatient ComplianceDegree of Soft Tissue Injury
Complex Intraarticular Fracture
Distal Humerus Fractures Mobilization
Begin when concerns for failure of fixation minimalTypically mobilize 2 weeks after distal Humerus ORIF, 4-6 weeks after complex fracture patternsPoor bone or poor fixation, immobilize for SIX WEEKS!!!Healed anatomic stiff fracture much easier to treat than failure of fixation…First shot is the best shot! CT Scan Evaluation
Distal Humerus Fractures Mobilization
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Olecranon Fractures
Olecranon Fractures
Capitellar Fractures
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Capitellar Fractures
Capitellar Fractures
Preoperative Incision
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Medial Window
Lateral Window
Subluxation Of Ulna Allows
Direct Humeral Exposure
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4 Weeks Postoperative
4 Weeks Postoperative
Case
52 y.o. active male s/p ORIF complex distal
humerus fracture
and removal of hardware with significant pain
and crepitus
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Case
76 y.owoman s/p ORIF complains of grinding noises from elbow
Case
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“I feel a bump on my elbow”
“I feel a bump on my elbow”
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Fix or Replace
Age of patient (Physiologic) Demands of the patient Fracture pattern Articular involvement Sagital fracture involvement Comorbidities
Conclusion
ORIF whenever possible Numerous complications with elbow replacement Lifetime functional limitations TEA good option low demand elderly patient if not fixable
Distal Biceps Ruptures
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Endobutton Technique
Endobutton Technique
Rehabilitation
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Distal biceps repairs protected x 6 weeksGentle active flexion and forearm rotation
with extension block at 90 degrees at 2 weeks. If poor quality tendon can wait 4-6 weeks. Strengthening at 3 monthsUnrestricted use at 4 – 6 months
Distal Biceps Rehabilitation
Chronic Distal Biceps Ruptures
Chronic Distal Biceps Repair
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Least common tendon injury
Males
Age 30 years
Avulsion fractures in Adolescents
Epidemiology
Flake Sign
Triceps Ruptures
Triceps Repair
Generally splinted for 4 weeks in full extension
Gentle AROM at 4 weeks, but if poor tendon repair wait 6 weeks
Gentle strengthening at 6 weeksUnrestricted activity at 6
months
Triceps Repairs
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ETIOLOGY Rare varus stressMost common cause
Elbow dislocation Lateral Epicondyle
nonunion Iatrogenic
Tennis elbow surgery Radial head excision
Posterolateral Rotary Instability(PLRI)
Tests for posterolateral rotatory instability
Supination-valgus moment is applied, causing subluxation at 40 degrees of flexion
Palpable, visible clunk Creates positive
apprehension
Lateral Pivot Shift Test
Lateral Pivot Shift Test
Dimpling
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Post Reduction
Potentially elderly, low demandRarely improves
nonoperativelyDaily function impairedHinged Elbow Brace
- With extension block, pronation
PRLI Conservative Treatment
LIGAMENT REPAIR
Origin AvulsedDirect RepairPlicate Capsule
PRLI Treatment
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PRLI Reconstruction
Surgical Exposure
Determination of Isocentric Point
Suture
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LUCL Reconstruction
Capsular Imbrication
Postoperative Closure
Splint in Pronation and Flexion- Splint at 70-80 Flexion- Wait 14 days before Flexion begun- Hinged Elbow Brace with Extension Block
Wean from brace 4-6 weeks3 Months protected activity6 Months activity as tolerated
PRLI Rehabilitation
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MCL Ruptures
NonoperativeNoncompetive athlete, particularly nonthrowing
Rehabilitation-Scapular stabilizers and rotator cuff muscles of ipsilateral shoulder-Flexor pronator mass strengthening, stretching-Grip exercises, slow progression
MCL Treatment Options
MCL Repair or Reconstruction
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“Docking” Procedure
Altchek, et al 2000
MCL Reconstruction
Splinted at 70 degrees flexion, protected for 6 weeks2 weeks – Active ROM4-6 Wks - Strengthening3-4 Months – Begin Throwing12-18 Months – Final Stages
MCL Repair or Reconstruction
Radial Head Fractures
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Radial Head Fractures
Radial Head Fractures
Splinted at 90 degrees flexion for 2 weeks2 weeks – Gentle AROM for ORIF
and Radial Head ReplacementIf complex ORIF begin AROM at 4
weeksResting Orthoplast splint at 90 for
comfort6 weeks splint discontinued
Isolated Radial Head Fractures
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TERRIBLE TRIADRadial head fracture, coronoid fracture, posterior elbow
dislocation
Terrible Triad Injuries
Case PresentationPugh, McKee
• Early operative repair
• Allowed earlier mobilization improving functional outcome
Radial Head Fragment
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Radial Head Fragment
Coronoid Fragment
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Posterior Approach
Radial Head Fracture
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Articular Delamination
LCL Avulsion
Articular Delamination
LCL Avulsion
Radial Head Fragments
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Coronoid Fracture
CoronoidFracture
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Splinted at 70 degrees flexion for 2 weeks2 weeks – Gentle PROM,
extension block at 70 in hinged elbow brace4 weeks – AAROM extension
block at 1356 weeks full extensionHinged Elbow brace for 3 months
Terrible Triad Injuries
Preoperative Radiographs
Heterotopic Ossification
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Preoperative Radiographs
Heterotopic Ossifcation
Posterior Approach
Medial Approach
Isolation of Ulnar Nerve
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Anterior Release
Posterior Release
Medial Access
Lateral Access
Lateral Access
Anterior Release
Posterior Release
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Heterotopic Ossification
Excision when mature on XraysIndomethacin 3 weeks postop Radiation in head injuries, or in
cases of severe HO formationDrain in for 24 hoursROM begins postop day oneCPM in certain complex casesCareful wound monitoring
necessary
Heterotopic Ossification Excision